英文精品课件chronic obstructive pulmonary disease （35p）

CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL PRACTICE GUIDELINES REVIEW WEEK 1: DIAGNOSIS AMBULATORY INTERNAL MEDICINE GROUP PRACTICE UNIVERSITY HEALTH NETWORK / MSH SEPTEMBER 2007 Prepared by: Dr. D. Panisko COPD: Guidelines for this Seminar o Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Celli BR et al. Eur Respir J 2004; 23: 932-46. Full document, with updates, available at: , accessed Sept 2007 o Canadian Thoracic Society recommendations for the management of chronic obstructive pulmonary disease - 2003. ODonnell DE et al. Can Respir J 2003; 10(SupplA): 11A- 33A o Global Initiative for Chronic Obstructive Lung Disease. (GOLD). A collaborative of the NIH and WHO. Updated Nov 2006, accessed Sept 2007. Available at COPD Diagnosis: Objectives oAfter this seminar you should: nbe aware of diagnostic clinical practice guidelines for stable chronic COPD nbe able to define COPD and asthma and outline a differential diagnosis nbe able list important historical and laboratory diagnostic features of COPD nbe able to describe the evidence-based physical examination for COPD and airflow limitation COPD I:DIAGNOSIS CASE: A 61 year old man comes to your clinic as a new patient. He had just been admitted to hospital for his first exacerbation of COPD. He has completed a 10 day antibiotic course and 10 days of oral Prednisone. He is now only on an ipratropium puffer, 2 puffs qid. o How is COPD defined ? What is emphysema ? What is asthma ? o Why is it important to make a diagnosis of COPD (as opposed to asthma) in this patient ? COPD I:DIAGNOSIS o COPD Definition: o A preventable and treatable disease state characterized by airflow limitation that is not fully reversible. o The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. o Although COPD affects the lungs, it also produces significant systemic consequences. o Implies post bronchodilator FEV1/FVC 80% predicted Stage II: Moderate FEV1/FVC 9 seconds: A, 4.8 oSubxiphoid Apical Impulse: B, 4.6 oPulsus Paradoxus 15mmHg: C, 3.7 oDecreased Breath Sounds: B, 3.7 oForced Expiratory Time 6 - 9 seconds: A, 2.7 * Many other signs not systematically evaluated (diaphragmatic levels, pursed lip breathing, use of accessory muscles, indrawing) COPD I:DIAGNOSIS o Straus et als important contributions to the literature have shown that a single physical sign is not as useful as a combination of historical and physical findings to make a diagnosis of COPD o They have published two models What maneuvre is being performed ? COPD I:DIAGNOSIS Combined history/physical exam Model I: Smoking 40 P.Y. (LR 8.3) Self reported history of COPD (LR 7.3) Maximum laryngeal height (LR 2.8) Age 45 years (LR 1.3) Combined all 4: +LR 220 Combined patients with none: -LR 0.13 COPD I:DIAGNOSIS Combined history/physical exam Model II: *Forced Exp Time 9 sec (LR 6.7) Multivariate: (LR 4.6) *Self reported history of COPD (LR 5.6) (LR 4.4) *Wheezing (LR 4.0) (LR 2.9) Smoked longer than 40 pack years (LR 3.3) Male gender (LR 1.6) Age over 65 years (LR 1.6) *Combined all 3: +LR 59.0 *Combined patients with none: -LR 0.3 COPD I:DIAGNOSIS CASE (cont.): o Physical examination of our patient was only relevant for a barrel chest, diffuse occasional audible wheezes, and a forced expiratory time of 7 seconds. Laryngeal height was 5 cm. o There were no signs of cor pulmonale. o Otherwise, the exam was unremarkable. COPD I:DIAGNOSIS CASE (cont.): o Which of the following investigations are currently indicated ? o How will they help in the care of this patient ? in the care of other patients with stable COPD ? nSpirometry nFull Pulmonary Function Tests nCXR nHelical CT of chest nAllergy testing nO2 saturation (rest, exercise, sleep) nABG COPD I:DIAGNOSIS o Spirometry: Performed for diagnosis, prognosis, monitoring of therapy. FEV1, FVC, and ratio most important; peak flows not recommended. o Pulmonary Function Tests: Full PFTs not necessary for routine dx, usually performed at the time of initial dx to establish baseline, may be useful for dxdx - i.e to obtain bronchodilator reversibility testing to asses for asthma. o CXR: Useful in exacerbations and for its r/o value for other dxdx. Has low sens. and spec. for the dx of emphysema, thus not recommended by guidelines. COPD I:DIAGNOSIS o Helical CT of Chest: Not necessary for routine diagnosis, may be useful for dxdx or for lung volume reduction OR. o Allergy Testing: May have use in asthma, not COPD. o O2 Sat: In severe COPD (stage 2b or 3) useful to guide O2 therapy. Nocturnal desaturations are probably under diagnosed. o ABG: Needed to guide long term oxygen therapy and to obtain government funding for same. (See guidelines for actual criteria for initiation of treatment will be discussed next week). COPD I:DIAGNOSIS CASE (cont.): o The current Canadian guidelines: ndo not emphasize evidence based diagnosis for patients with COPD nput more emphasis on evaluation of impairment, disability with exercise testing, dyspnea assessment scales, and quality of life assessment scales ndo not give specific recommendations on how or at what point in the patients course these evaluations should be used COPD: other useful references: o 2 recent review series on COPD: n5 article